Virginia ›Harrisonburg

Harrisonburg HLTH & Rehab CNTR

1225 Reservoir Street, Harrisonburg, VA 22801 · Harrisonburg City County · 180 certified beds · avg 174 residents/day · certified since Feb 19, 1975

Abuse citation flag (CMS)

Part of chain: LIFEWORKS REHAB (64 facilities, chain avg rating 2.1★)

The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.

1/5
Health inspection rating (on-site)
5
Serious findings on record
$232,008
Fines, last 3 years
2.76
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, facility-wide · Feb 13, 2026 · F-0689

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (L): A life-threatening or extremely dangerous situation existed throughout the facility. The single most serious citation CMS can issue.

Corrected: Jul 7, 2026 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, repeated · Apr 11, 2025 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.

Corrected: May 21, 2025 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, one-off · Apr 11, 2025 · F-0600 · triggered by a complaint

The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.

Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: May 21, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Apr 11, 2025 · F-0690 · triggered by a complaint

The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.

Why it matters: Poor continence and catheter care leads to infections, skin breakdown, and loss of dignity.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: May 21, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Apr 11, 2025 · F-0692 · triggered by a complaint

The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.

Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: May 21, 2025 (Deficient, Provider has date of correction)

All citations in the current public record (81)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
Jun 10, 2026E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Apr 15, 2026E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Feb 13, 2026▲ L · Immediate jeopardy, facility-wideThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Feb 13, 2026F · Potential for harm, facility-wideThe facility did not regularly inspect bed frames, mattresses, and bed rails for safety, or the rails and mattresses were not attached safely to the frames.
Feb 13, 2026E · Potential for harm, repeatedThe facility did not honor residents' right to form and take part in resident or family groups, such as a resident council.
Feb 13, 2026E · Potential for harm, repeatedThe facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered.
Feb 13, 2026E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Feb 13, 2026E · Potential for harm, repeatedThe facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly.
Feb 13, 2026E · Potential for harm, repeatedThe facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
Feb 13, 2026E · Potential for harm, repeatedThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Feb 13, 2026E · Potential for harm, repeatedThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Feb 13, 2026E · Potential for harm, repeatedThe facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them.
Feb 13, 2026E · Potential for harm, repeatedThe facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices.
Feb 13, 2026E · Potential for harm, repeatedThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint
Feb 13, 2026D · Potential for harm, one-offThe facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
Feb 13, 2026D · Potential for harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Feb 13, 2026D · Potential for harm, one-offThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Feb 13, 2026D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Feb 13, 2026D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Feb 13, 2026D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Feb 13, 2026D · Potential for harm, one-offThe facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes.
Feb 13, 2026D · Potential for harm, one-offThe facility did not dispose of garbage and refuse properly.
Feb 13, 2026D · Potential for harm, one-offThe facility did not develop or maintain an effective training program for its direct care staff, including training on how to communicate effectively with residents.
Feb 13, 2026D · Potential for harm, one-offThe facility did not give all staff the required training on its quality improvement program — the internal system for finding problems and making care better.
Feb 13, 2026D · Potential for harm, one-offThe facility did not provide its staff with training in compliance and ethics — teaching employees the laws and ethical standards that govern how residents must be treated.
Sep 24, 2025E · Potential for harm, repeatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Sep 24, 2025D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Sep 24, 2025D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Sep 24, 2025D · Potential for harm, one-offThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint
Sep 24, 2025D · Potential for harm, one-offThe facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · from a complaint
Jun 5, 2025E · Potential for harm, repeatedThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Jun 5, 2025D · Potential for harm, one-offThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint
Apr 11, 2025▲ K · Immediate jeopardy, repeatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Apr 11, 2025▲ J · Immediate jeopardy, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Apr 11, 2025▲ G · Actual harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint
Apr 11, 2025▲ G · Actual harm, one-offThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint
Apr 11, 2025F · Potential for harm, facility-wideThe facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint
Apr 11, 2025E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Apr 11, 2025E · Potential for harm, repeatedThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Apr 11, 2025E · Potential for harm, repeatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Apr 11, 2025E · Potential for harm, repeatedThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint
Apr 11, 2025E · Potential for harm, repeatedThe facility did not provide its staff with required training on behavioral health — caring for residents with conditions like dementia, depression, or other mental health needs. · from a complaint
Apr 11, 2025D · Potential for harm, one-offThe facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint
Apr 11, 2025D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Apr 11, 2025D · Potential for harm, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Apr 11, 2025D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint
Apr 11, 2025D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Apr 11, 2025D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Apr 11, 2025D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Apr 11, 2025D · Potential for harm, one-offThe facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation. · from a complaint
Apr 11, 2025D · Potential for harm, one-offThe facility did not include required infection control training — with written standards, policies, and procedures — as part of its infection prevention program. · from a complaint
Jul 2, 2024E · Potential for harm, repeatedThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint
Jul 2, 2024D · Potential for harm, one-offThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint
Jan 17, 2024D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Jan 17, 2024D · Potential for harm, one-offThe facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. · from a complaint
Aug 23, 2023E · Potential for harm, repeatedThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Aug 23, 2023D · Potential for harm, one-offThe facility did not provide or obtain laboratory tests when a doctor ordered them, or did not promptly report the results back to the doctor who ordered them. · from a complaint
May 26, 2022E · Potential for harm, repeatedThe facility did not honor residents' right to manage their own money and financial affairs.
May 26, 2022E · Potential for harm, repeatedThe facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need.
May 26, 2022E · Potential for harm, repeatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
May 26, 2022E · Potential for harm, repeatedThe facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety.
May 26, 2022E · Potential for harm, repeatedThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
May 26, 2022E · Potential for harm, repeatedThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
May 26, 2022E · Potential for harm, repeatedThe facility did not provide each resident with a nourishing, tasty, well-balanced diet that meets their daily nutritional and special dietary needs.
May 26, 2022E · Potential for harm, repeatedThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
May 26, 2022D · Potential for harm, one-offThe facility did not keep residents' personal and medical information private and confidential.
May 26, 2022D · Potential for harm, one-offThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
May 26, 2022D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
May 26, 2022D · Potential for harm, one-offThe facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
May 26, 2022D · Potential for harm, one-offThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
May 26, 2022D · Potential for harm, one-offThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
May 26, 2022D · Potential for harm, one-offThe facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life.
May 26, 2022C · Minimal risk, facility-wideThe facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately.
Apr 22, 2021E · Potential for harm, repeatedThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care.
Apr 22, 2021D · Potential for harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Apr 22, 2021D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Apr 22, 2021D · Potential for harm, one-offThe facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable.
Apr 22, 2021D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Apr 22, 2021D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Apr 22, 2021D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Apr 22, 2021B · Minimal risk, repeatedThe facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (16 → 23).

YearCitationsSerious (G–L)Worst severity that year
202180E
2022160E
202320E
202440E
2025264K ▲
2026251L ▲

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

2 fines totaling $232,008, plus 1 Medicare payment denial period.

DateTypeAmount / length
Feb 13, 2026Fine$112,785
Feb 13, 2026Payment Denial55 days from May 23, 2026
Apr 11, 2025Fine$119,223

Nurse staffing (from payroll records, adjusted for how much care residents need)

MeasureThis facilityVirginia avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)2.763.673.95bottom 10% in Virginia; bottom 7% in the U.S.
Registered Nurse hours0.240.660.69bottom 2% in Virginia; bottom 5% in the U.S.
Weekend total nurse staffing2.383.213.50bottom 11% in Virginia; bottom 6% in the U.S.
Weekend RN hours (not acuity-adjusted)0.140.460.48bottom 4% in Virginia; bottom 4% in the U.S.
Total nursing staff turnover (%)60.048.145.8bottom 22% in Virginia; bottom 17% in the U.S.
RN turnover (%)56.348.242.9bottom 34% in Virginia; bottom 26% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.17, RN 0.28, weekend 2.73. Staffing rating: 1/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: 3/5

Who owns this facility

For profit - Limited Liability company

Owner / managerTypeRoleStakeSince
America West LLCOrganization5% or Greater Indirect Ownership Interest—05/28/2021
Charles 1994 & Family LLCOrganization5% or Greater Indirect Ownership Interest—05/28/2021
Charles 1994 Family Grantor TrustOrganization5% or Greater Indirect Ownership Interest—05/28/2021
Charles 1994 LLCOrganization5% or Greater Indirect Ownership Interest—05/28/2021
Edward 1998 Family Grantor TrustOrganization5% or Greater Indirect Ownership Interest—05/28/2021
Harrisonburg Holdings I LLCOrganization5% or Greater Direct Ownership Interest100%05/28/2021
KSS 2000 Family TrustOrganization5% or Greater Indirect Ownership Interest—05/28/2021
ML 2000 Family TrustOrganization5% or Greater Indirect Ownership Interest—05/28/2021
MRV West LLCOrganization5% or Greater Indirect Ownership Interest—05/28/2021
Redrock West LLCOrganization5% or Greater Indirect Ownership Interest—05/28/2021
Saul 2012 Family Grantor TrustOrganization5% or Greater Indirect Ownership Interest—05/28/2021
Saul 2012 LLCOrganization5% or Greater Indirect Ownership Interest—05/28/2021
Brooks, MatthewIndividualW-2 Managing EmployeeNOT APPLICABLE09/11/2023
RCZBM West Manager LLCOrganizationOperational/Managerial ControlNOT APPLICABLE05/28/2021

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

Nearby facilities (within 20 miles)

FacilityDistanceCityOverallInspectionFlags
Sunnyside Presbyterian Retirement Community1.0 miHarrisonburg, VA★★★★★5/5
Blue Ridge Rehabilitation and Nursing1.7 miHarrisonburg, VA★★☆☆☆2/5
VMRC, Complete Living Care3.1 miHarrisonburg, VA★★★☆☆4/5
Bridgewater Home , INC.7.3 miBridgewater, VA★★★★☆3/5
Life Care Center of New Market18.0 miNew Market, VA★★★★★4/5

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Facility data as of CMS processing date 2026-08-01. CCN 495093.